Uninterrupted Continuation of VV-ECMO Without Anticoagulation for 44 Days in COVID-19 ARDS: A Precarious Quandary.

Venovenous extracorporeal membrane oxygenation (VV-ECMO) has become a mainstay treatment modality for a select patient population who do not respond to conventional medical therapy suffering from severe acute respiratory distress syndrome (ARDS) due to COVID-19. This therapy necessitates the utilization of anticoagulation, whether unfractionated heparin or bivalirudin, to prevent thrombotic complications. Scarce are reports of VV-ECMO implementation leading to acute hemorrhage mandating cessation of anticoagulation in a patient suffering from COVID-19 ARDS. Herein, the authors report a case of a successful outcome in a COVID-19 ARDS patient who suffered an acute hemorrhagic complication leading to pre-emptive termination of systemic anticoagulation. The authors believe this to be one of the first such cases in the literature.

Right Ventricular Failure Manifesting in Corona Virus Disease 2019 Acute Respiratory Distress Syndrome: A Call to Transition from Venovenous Extracorporeal Membranous Oxygenation to Right Ventricular Assist Device Extracorporeal Membranous Oxygenation.

Often labeled the forgotten ventricle, the right ventricle's (RV) importance has been magnified over the last 2 years as providers witnessed how severe acute respiratory syndrome coronavirus 2 infection has a predilection for exacerbating RV failure. Venovenous extracorporeal membranous oxygenation (VV-ECMO) has become a mainstay treatment modality for a select patient population suffering from severe COVID-19 acute respiratory distress syndrome. Concomitant early implementation of a right ventricular assist device with ECMO (RVAD-ECMO) may confer benefit in patient outcomes. The underlying mechanism of RV failure in COVID-19 has a multifactorial etiopathogenesis; nonetheless, clinical evaluation of a patient necessitating RV support remains unchanged. Herein, the authors report the case of a critically ill patient who was transitioned from a conventional VV-ECMO Medtronic Crescent cannula to RVAD-ECMO, with the insertion of the LivaNova ProtekDuo dual-lumen RVAD cannula.

Rescue Echocardiography/Ultrasonography in the Management of Combined Cardiac Surgical and Medical Patients in a Cardiac Intensive Care Unit.

OBJECTIVES: Rescue point-of-care ultrasound (r-POCUS) in critical care medicine has revolutionized the management of critically ill patients with hemodynamic instability. However, clinical studies on its use among high-risk cardiac patients still are limited. The authors aimed to assess the utility of r-POCUS for managing high-risk cardiac patients in a mixed cardiac-surgical and cardiac-medical intensive care unit (ICU) in a quaternary care hospital by reviewing the indications and findings of r-POCUS and subsequent effect on patient management. DESIGN: Retrospective observational study. DESIGN: Single institution, quaternary care hospital. PARTICIPANTS: The study comprised 189 consecutive r-POCUS examinations performed in a cardiac medical and surgical ICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: r-POCUS was performed on 141 patients. Common indications for r-POCUS included hypotension (n = 93 [49%]), assessment of extracorporeal membrane oxygenation (ECMO) and ventricular assist devices (n = 33 [17%]), arrhythmias (n = 13 [7%]), abnormal pulmonary artery catheter values (n = 11 [6%]), and ischemic electrocardiogram changes (n = 10 [5%]). Cardiac pathology was positive in 129 (68%) of the rescue examinations. Common reported pathologies included left ventricular dysfunction (n = 47 [25%]), right ventricular dysfunction (n = 52 [28%]), hypervolemia (n = 13 [7%]), hypovolemia (n = 25 [13%]), pericardial effusion/tamponade (n = 21 [11%]), and ECMO/ventricular assist device cannula malposition (n = 9 [5%]). Seventy-five percent of the rescue examinations resulted in medical and surgical interventions, including fluid resuscitation (n = 25 [13%]), diuresis (n = 14 [7%]), ionotropic support (n = 23 [12%]), surgical intervention in the operating room (n = 21 [11%]), surgical intervention at the bedside (n = 8 [4%]), ECMO initiation (n = 15 [8%]), and ECMO/ventricular assist device cannula/setting adjustment (n = 12 [6%]). CONCLUSION: In this retrospective study, r-POCUS performed by attending intensivists resulted in diverse findings and was associated with rapid changes in clinical management of patients in a high-acuity, mixed cardiac-surgical and cardiac-medical ICU.

Extracorporeal Cardiopulmonary Resuscitation: Outcomes and Complications at a Quaternary Referral Center.

OBJECTIVE: At a quaternary care center that regularly performs and cares for patients undergoing extracorporeal cardiopulmonary resuscitation (eCPR), a database of all adult patients who underwent eCPR with venoarterial extracorporeal membrane oxygenation (ECMO) over a 10-year period was reviewed. Seventy-one eCPR patients were analyzed to compare outcomes and complication rates. The authors hypothesized that evidence of end-organ injury, such as the need for continuous renal replacement therapy, in their institution's eCPR population would be associated with increased in-hospital mortality. DESIGN: Retrospective chart review of prospectively collected data at a quaternary care center. SETTING: Single quaternary academic referral center for ECMO. PARTICIPANTS: The study comprised adult patients who underwent venoarterial ECMO for eCPR from 2009-2019 and for whom demographic data, survival data, and complication rates were available. INTERVENTIONS: None-this was a retrospective chart review. MEASUREMENTS AND MAIN RESULTS: eCPR survival was 53.5% (38 of 71), and hospital survival was 33.8% (24 of 71). The most common complications were hemorrhage (26 of 67), renal failure (19 of 67), and neurologic injury (14 of 67). Of 19 patients requiring renal replacement therapy, only 1 survived to hospital discharge (5.3%) versus 23 of 48 patients without renal failure (47.9%) surviving to discharge (p = 0.001). CONCLUSIONS: In this cohort of 71 patients who underwent eCPR, outcomes were promising; however, complication rates were high, and renal failure in particular demonstrated an extremely high mortality. These are single-institution results that should be followed up with larger multicenter cohorts of eCPR patients.

Outcomes of Venoarterial Extracorporeal Membrane Oxygenation Patients Requiring Multiple Episodes of Support.

OBJECTIVES: This study describes the largest North American single-institution experience with adult patients requiring multiple extracorporeal membrane oxygenation (ECMO) runs in the same admission and aims to describe outcomes of survival and complication rates in this patient population. DESIGN: A retrospective chart review-based study in a single quaternary care center of venoarterial (VA) ECMO patients cannulated multiple times on ECMO support to assess for outcomes and survival (both of ECMO therapy and survival to discharge). SETTING: Single quaternary academic center for ECMO. PARTICIPANTS: All patients undergoing VA ECMO who were at least 18 years of age from 2011 to 2019, composed of a total of 14 patients requiring multiple cannulations. INTERVENTIONS: None, this was a retrospective chart review. MEASUREMENTS AND MAIN RESULTS: Of the 326 patients reviewed, 14 patients (4.3% of all patients in the database) had multiple ECMO therapies. The average patient age was 55.2 ± 10.99 years of age, and 57% were female; 4 of the 14 (28.6%) patients survived to hospital discharge. The top 2 indications for initial VA ECMO therapy were cardiogenic shock after myocardial infarction (35.7%) and after cardiotomy shock (35.7%). For repeated cannulation, the most common cause was hypoxia (64%, 9 patients), with 6 of these patients requiring a right ventricular assist device plus oxygenator. Other causes for repeated cannulation included post-cardiotomy shock (14%), recurrent ventricular tachycardia (14%), and cardiogenic shock (7%). All patients who required continuous venovenous hemofiltration during their first run of ECMO did not survive to discharge. CONCLUSIONS: Fourteen of 326 patients in the authors' VA ECMO database required additional ECMO therapy after decannulation; this represents at least 1 to 2 cases per year at higher-volume centers. Despite the small number of patients in this retrospective review, it seems that certain patients are reasonable candidates for additional ECMO therapy should their cardiopulmonary function again decline. The findings of renal replacement therapy and infection being more common during a second ECMO run are logical, but larger cohorts (ideally multicenter or from within the Extracorporeal Life Support Organization registry) are required to validate these preliminary findings.

Predictors of Neurologic Recovery in Patients Who Undergo Extracorporeal Membrane Oxygenation for Refractory Cardiac Arrest.

OBJECTIVE: Extracorporeal membrane oxygenation (ECMO) as a rescue strategy during cardiopulmonary resuscitation (ECPR) is increasingly being used for nonresponders to conventional cardiopulmonary resuscitation. To identify patients most likely to benefit from ECPR, the authors investigated predictors of hospital discharge with good neurologic function. DESIGN: Retrospective cohort analysis. SETTING: Single institution academic medical center. PARTICIPANTS: Patients who underwent ECPR. INTERVENTIONS: Venoarterial ECMO initiation for witnessed refractory cardiac arrest from 2009-2019. MEASUREMENTS AND MAIN RESULTS: Baseline characteristics and post-ECMO outcomes were compared between patients who had good versus poor neurologic function at discharge. Good neurologic function was defined as a cerebral performance category 1 to 2, whereas poor neurologic function was defined as a cerebral performance category 3 to 5. Of 54 patients, 13 (24%) were discharged with good neurologic function and 41 (76%) had poor neurologic function (n = 38 in-hospital deaths; n = 3 discharged with severe disability.) Survivors with good neurologic function were younger (41 v 61 y; p = 0.03), more likely to arrest because of pulmonary embolism (46% v 10%; p = 0.01), and more likely to receive concurrent Impella (Abiomed, Danvers, MA) placement while on ECMO (38% v 12%; p = 0.03.) Young age was the most important predictor of good neurologic function (odds ratio 0.92 [0.87-0.97]; p = 0.004), with a threshold for improved survival around 60 years. For all patients, survival to discharge was 30%; however, among survivors with good neurologic function, 5-year survival was 100%. CONCLUSIONS: ECPR is associated with high rates of neurologic morbidity and mortality. However, in select patients, it may be an acceptable option with favorable long-term survival. Additional studies are indicated to further define the appropriate selection criteria for ECPR implementation.

Extracorporeal Membrane Oxygenation Is a Team Sport: Institutional Survival Benefits of a Formalized ECMO Team.

OBJECTIVES: At the authors' institution, prior to 2014, patients requiring care in the peri-extracorporeal membrane oxygenation (ECMO) period were treated by intensivists with specific training in ECMO but worked independently. This isolated form of care was addressed in late 2013 with the formal initiation of an ECMO team. The authors wanted to assess the difference in overall mortality for ECMO patients cared for prior to the initiation of a multidisciplinary team compared to after its establishment. DESIGN: This was a retrospective chart review-based study. SETTING: This was a single-center university-based hospital setting. PARTICIPANTS: The study included all adult patients at the authors' institution who required ECMO support between the years 2009 and 2017. INTERVENTIONS: The new multidisciplinary ECMO team established a set of protocols and guidelines to care for ECMO patients. The formal ECMO team consisted of cardiac surgery, cardiac anesthesia, intensivists, cardiology heart failure specialist, intensive care unit nursing (NP/RN), perfusion services, respiratory therapy, nutrition, physical and occupational therapy, and an ethics committee member. MEASUREMENTS AND MAIN RESULTS: Manual chart review was conducted and survival to discharge was collected and separated into 2 groups, 2009 to 2013 (pre-ECMO team) and 2014 to 2017 (post-ECMO team). In a total of 279 charts reviewed, patients required ECMO support. Survival to discharge for patients between 2009 and 2013 was 37.7% compared to a survival to discharge of 52.3% between 2014 and 2017 (p value = 0.02). CONCLUSIONS: Patients cared for after the initiation of an ECMO team showed improved survival compared to patients cared for prior to the creation of the ECMO team.

Echocardiographic Assessment of Biventricular Function in 249 Patients During the Peri-Extracorporeal Membrane Oxygenation Period.

OBJECTIVES: At a quaternary care center that regularly performs and cares for patients undergoing extracorporeal membrane oxygenation (ECMO), a database of all adult patients since 2009 was assembled with echocardiographic parameters of left (LV) and right (RV) ventricular function. From the database, 175 venoarterial (VA) and 74 venovenous (VV) ECMO patients were analyzed to compare the decannulation echocardiographic assessments of biventricular function before, during, and after ECMO in survivors and nonsurvivors. DESIGN: Retrospective chart review-based study. SETTING: A single quaternary care center. PARTICIPANTS: All adult patients who received ECMO from 2009 to 2017 with both survival data and echographic studies were included in this retrospective study. INTERVENTIONS: When indicated, transthoracic and transesophageal echocardiograms were performed for ECMO patients. The results of these echocardiograms were reviewed retrospectively, and differences between survivors and nonsurvivors were examined. MEASUREMENTS AND MAIN RESULTS: A retrospective chart review of before, during cannulation, and after decannulation echocardiographic assessments of biventricular function was performed. On average, VA ECMO survivors had better post-decannulation LV function than did nonsurvivors by a full clinical grade-mild impairment versus moderate impairment (p < 0.001). RV function comparison was similar-mild impairment in survivors versus moderate impairment in nonsurvivors (p = 0.007). LV and RV function before and during ECMO in survivors was not different from that of nonsurvivors. The change in biventricular function from before to after cannulation and during cannulation to post-cannulation was approximately a full clinical grade better in survivors than nonsurvivors (p < 0.01 in all cases). In VV ECMO patients, post-decannulation RV function was significantly worse in nonsurvivors (moderate dysfunction vs borderline normal function) (p = 0.013). CONCLUSIONS: Retrospective chart review of 249 patients suggests that echocardiographic assessment of biventricular function before ECMO cannulation is not prognostic in VA or VV ECMO patients. Post-decannulation assessment of biventricular function may aid in triaging more "at risk" patients because nonsurvivors have significantly worse biventricular function after decannulation. The failure to improve biventricular function from the before to after ECMO phases and the during to after ECMO phases is concerning for a poor prognosis.

A 266 Patient Experience of a Quaternary Care Referral Center for Extracorporeal Membrane Oxygenation with Assessment of Outcomes for Transferred Versus In-House Patients.

OBJECTIVE: Patients undergoing venoarterial extracorporeal membrane oxygenation (VA-ECMO) require highly trained specialists and resources to be cared for safely. Interestingly, comparisons of outcomes for patients cannulated for VA-ECMO by outside institutions and transferred to referral centers for further care versus those cannulated and taken care of in house at the referral center have not been reported on a large scale. This study aimed to perform the first comparison of these 2 populations based on the experience of a single quaternary referral center. DESIGN: A retrospective chart review-based study in a single quaternary care center of patients cannulated by referring institutions for VA-ECMO then transferred versus patients who were cannulated in house was performed to assess for a difference in survival (both of ECMO therapy and survival to discharge). SETTING: Single quaternary academic referral center for ECMO. PARTICIPANTS: All patients undergoing VA-ECMO who were at least 18 years old from 2011-2018 (266 patients). INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: The study comprised 215 patients cannulated for VA-ECMO in house and 51 patients cannulated by 17 different outside institutions then transferred. Survival of the ECMO run for in-house patients (122/215) was 56.7% (95% confidence interval [CI] 50.1-63.3), and survival of transferred patients (31/51) for the ECMO run was 60.8% (95% CI 47.4-74.2; p = 0.58). Survival to discharge in patients cannulated in house (82/215) was 38.1% (95% CI 31.6-44.6) and for outside hospital transfers (24/51 patients) was 47.1% (95% CI 33.4-60.8; p = 0.23). CONCLUSIONS: This retrospective chart review of 266 patients found no difference in survival of the ECMO therapy or survival to discharge in patients cannulated by other institutions and transferred versus those who were cannulated in house. Even though analysis on the feasibility of transfer centers has been performed extensively in patients with respiratory failure requiring venovenous ECMO, minimal investigation has been performed in patients requiring VA-ECMO. These results should be considered hypothesis-generating because larger sample sizes are necessary to guide care of these patients more definitively.

Pain management and safety profiles after preoperative vs postoperative thoracic epidural insertion for bilateral lung transplantation.

OBJECTIVE: Thoracic epidural analgesia provides effective pain control after lung transplantation; however, the optimal timing of placement is controversial. We sought to compare pain control and pulmonary and epidural morbidity between patients receiving preoperative vs postoperative epidurals. METHODS: Institutional records were reviewed for patients undergoing a bilateral lung transplant via a bilateral anterior thoracotomy with transverse sternotomy incision between January 2014 and January 2017. Pain control was measured using visual analog scale pain scores (0-10). Pulmonary complications included a composite of pneumonia, prolonged intubation, and reintubation/tracheostomy. RESULTS: Among 103 patients, 72 (70%) had an epidural placed preoperatively and 31 (30%) had an epidural placed within 72 hours posttransplant. There were no differences in the rates of cardiopulmonary bypass (3% vs 0%, P = 0.59); however, patients with a preoperative epidural were less likely to be placed on extracorporeal membrane oxygenation intraoperatively (25% vs 52%, P = 0.01). Pain control was similar at 24 hours (1.2 vs 1.7, P = 0.05); however, patients with a preoperative epidural reported lower pain scores at 48 (1.2 vs 2.1, P = 0.02) and 72 hours posttransplant (0.8 vs 1.7, P = 0.02). There were no differences in primary graft dysfunction (42% vs 56%, P = 0.28), length of mechanical ventilation (19.5 vs 24 hours, P = 0.18), or adverse pulmonary events (33% vs 52%, P = 0.12). No adverse events including epidural hematoma, paralysis, or infection resulted from epidural placement. CONCLUSION: Preoperative thoracic epidural placement provides improved analgesia without increased morbidity following lung transplantation.

Impella Placement Guided by Echocardiography Can Be Used as a Strategy to Unload the Left Ventricle During Peripheral Venoarterial Extracorporeal Membrane Oxygenation.

OBJECTIVE: At the authors' institution, before 2015, patients cannulated for peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) did not undergo left ventricular (LV) decompression with the use of an LV vent. After 2015, the authors' institution began using the Impella device to vent the left ventricle in patients on VA-ECMO. The authors hypothesized that survival outcomes would improve in patients on VA-ECMO with the use of an Impella for LV venting. DESIGN: Retrospective, chart based review study. SETTING: Single center, university-based hospital. PARTICIPANTS: All adult patients at the authors' institution who required VA-ECMO between January 2015 and May 2017. INTERVENTION: An Impella (Abiomed, Danvers, MA) device was placed percutaneously in patients cannulated for VA-ECMO as a mechanism to provide LV venting and decompression, therefore unloading the heart. MEASUREMENTS AND MAIN RESULTS: Manual chart review was conducted, and a survival analysis was performed. It was observed that patients on VA-ECMO in whom an Impella was implanted had improved survival and an improvement in LV function as demonstrated by echocardiography compared with patients maintained on VA-ECMO alone. CONCLUSIONS: Patients on VA-ECMO plus Impella implantation demonstrated improved survival compared with patients treated with VA-ECMO alone. Key echocardiographic characteristics such as improved LV function after Impella placement and LV cavity size reduction during therapy may help predict those patients who may benefit most from this cannulation strategy.

High incidence of epileptiform activity in adults undergoing extracorporeal membrane oxygenation.

OBJECTIVE: The prevalence of seizures and other types of epileptiform brain activity in patients undergoing extracorporeal membrane oxygenation (ECMO) is unknown. We aimed to estimate the prevalence of seizures and ictal-interictal continuum patterns in patients undergoing electroencephalography (EEG) during ECMO. METHODS: Retrospective review of a prospective ECMO registry from 2011-2018 in a university-affiliated academic hospital. Adult subjects who had decreased level of consciousness and underwent EEG monitoring for seizure screening were included. EEG classification followed the American Clinical Neurophysiology Society criteria. Poor neurological outcome was defined as a Cerebral Performance Category of 3-5 at hospital discharge. RESULTS: Three hundred and ninety-five subjects had ECMO, and one hundred and thirteen (28.6%) had EEG monitoring. Ninety-two (23.3%) subjects had EEG performed during ECMO and were included in the study (average EEG duration 54 h). Veno-arterial ECMO was the most common cannulation strategy (83%) and 26 (28%) subjects had extracorporeal cardiopulmonary resuscitation. Fifty-eight subjects (63%) had epileptiform activity or ictal-interictal continuum patterns on EEG, including three (3%) subjects with nonconvulsive status epilepticus, 33 (36%) generalized periodic discharges, and 4 (5%) lateralized periodic discharges. Comparison between subjects with or without epileptiform activity showed comparable in-hospital mortality (57% vs. 47%, p = 0.38) and poor neurological outcome (and 56% and 36%, p = 0.23). Twenty-seven subjects (33%) had acute neuroimaging abnormalities (stroke N = 21). CONCLUSIONS: Seizures and ictal-interictal continuum patterns are commonly observed in patients managed with ECMO. Further studies are needed to evaluate whether epileptiform activity is an actionable target for interventions. SIGNIFICANCE: Epileptiform and ictal-interictal continuum abnormalities are frequently observed in patients supported with ECMO undergoing EEG monitoring.

Outcomes of Adult Patients With Septic Shock Undergoing Extracorporeal Membrane Oxygenation Therapy.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) has been shown to provide benefits in children, but not adults, with septic shock. This study described the clinical outcomes of adults in septic shock who underwent ECMO. METHODS: This study retrospectively investigated adults who were supported on venoarterial or venovenous modes of ECMO and who had septic shock at the time of cannulation from January 1, 2009 to December 31, 2016 at a quaternary medical center in the United States. The primary outcomes were rate of survival to hospital discharge and time to survival using Kaplan-Meier survival estimates. This study analyzed survival by mode, previous cardiac arrest, and timing of cannulation (<96 and ≥96 hours after admission to the intensive care unit). Secondary outcomes were complications and days of ECMO support, length of stay in the intensive care unit, and hospitalization days. RESULTS: Of 243 patients supported on ECMO during this 7-year period, 32 met the criteria for septic shock, and the majority had a pulmonary source of infection (72%). The most common mode of support was venovenous ECMO (65%), and median ejection fraction was 51%. Median time on ECMO was 5.8 days (interquartile range, 2.6, 11.3 days). Survival to hospital discharge was 13 of 32 (41%), whereas median survival was 14.5 days (interquartile range, 5.2, 23.7 days). There was no statistically significant difference in survival by subgroup, including ECMO mode. Health care-associated infections were frequent (25%). CONCLUSIONS: This cohort of patients undergoing ECMO had equivalent median survival compared with literature-based estimates of other cohorts of patients with septic shock.

Sepsis induced cardiomyopathy: Pathophysiology and use of mechanical circulatory support for refractory shock.

Sepsis remains a major cause of morbidity and mortality, and sepsis-induced cardiomyopathy (SCM) has been recognized as a relevant complication. In this article, the pathophysiology of SCM and the literature regarding the clinical care with a focus on the use of mechanical circulatory support for the rescue of patients with severe SCM are reviewed. Lastly, a pragmatic approach to the care of this complex patient population is provided using a representative case example.

Minimizing ICU Neurological Dysfunction with Dexmedetomidine-induced Sleep (MINDDS): protocol for a randomised, double-blind, parallel-arm, placebo-controlled trial.

INTRODUCTION: Delirium, which is prevalent in postcardiac surgical patients, is an acute brain dysfunction characterised by disturbances in attention, awareness and cognition not explained by a pre-existing neurocognitive disorder. The pathophysiology of delirium remains poorly understood. However, basic science and clinical studies suggest that sleep disturbance may be a modifiable risk factor for the development of delirium. Dexmedetomidine is a α-2A adrenergic receptor agonist medication that patterns the activity of various arousal nuclei similar to sleep. A single night-time loading dose of dexmedetomidine promotes non-rapid eye movement sleep stages N2 and N3 sleep. This trial hypothesises dexmedetomidine-induced sleep as pre-emptive therapy for postoperative delirium. METHODS AND ANALYSIS: The MINDDS (Minimizing ICU Neurological Dysfunction with Dexmedetomidine-induced Sleep) trial is a 370-patient block-randomised, placebo-controlled, double-blinded, single-site, parallel-arm superiority trial. Patients over 60 years old, undergoing cardiac surgery with planned cardiopulmonary bypass, will be randomised to receive a sleep-inducing dose of dexmedetomidine or placebo. The primary outcome is the incidence of delirium on postoperative day 1, assessed with the Confusion Assessment Method by staff blinded to the treatment assignment. To ensure that the study is appropriately powered for the primary outcome measure, patients will be recruited and randomised into the study until 370 patients receive the study intervention on postoperative day 0. Secondary outcomes will be evaluated by in-person assessments and medical record review for in-hospital end points, and by telephone interview for 30-day, 90-day and 180-day end points. All trial outcomes will be evaluated using an intention-to-treat analysis plan. Hypothesis testing will be performed using a two-sided significance level (type I error) of α=0.05. Sensitivity analyses using the actual treatment received will be performed and compared with the intention-to-treat analysis results. Additional sensitivity analyses will assess the potential impact of missing data due to loss of follow-up. ETHICS AND DISSEMINATION: The Partners Human Research Committee approved the MINDDS trial. Recruitment began in March 2017. Dissemination plans include presentations at scientific conferences, scientific publications and popular media. TRIAL REGISTRATION NUMBER: NCT02856594.

Fenoldopam in critically ill patients with early renal dysfunction. A crossover study.

BACKGROUND: Acute kidney injury is a frequent problem among many critically ill patients, commonly in the context of multiple organ failure and decreased renal perfusion. Its presence conveys a poor prognosis. Currently, effective therapeutic interventions are limited and dopaminergic agonists have been suggested as an option to prevent further damage. METHODS: We performed a randomized, double-blinded, prospective crossover study in 17 patients admitted to our trauma intensive care unit (ICU) with evidence of impaired renal function. Patients were randomized to a 24-h intravenous infusion of low-dose fenoldopam or placebo. When the infusion of fenoldopam or placebo was completed, patients underwent a 24-h "washout" period in which no study intervention was performed. This sequence was repeated in each patient with the opposite agent, so each patient served as his own control. Four-hour creatinine collections were taken during the last 4 h of each infusion and washout periods to determine creatinine clearance changes during and after the administration of the study drug. RESULTS: The creatinine clearance was higher with fenoldopam infusion than with placebo infusion (P = 0.045). The FENa was not significantly different. CONCLUSIONS: Our study showed that low-dose Fenoldopam increases creatinine clearance in the critically ill with renal insufficiency. Fenoldopam may be a useful drug in ICU patients with early renal dysfunction.

Irrigación de las glándulas suprarrenales en el período fetal / Irrigation of the adrenal glands in the fetal period

Se hace un estudio anatómico de la revascularización de las glándulas suprarrenales en el feto